Comparative analysis of 2 approaches to monitor countries' progress towards full and equal access to sexual and reproductive health care, information, and education in 75 countries: An observational validation study.

Abstract

Background: Sustainable Development Goal (SDG) Indicator 5.6.2 is the "Number of countries with laws and regulations that guarantee full and equal access to women and men aged 15 years and older to sexual and reproductive health care, information, and education." This indicator plays a key role in tracking global progress toward achieving gender equity and empowerment, ensuring its validity is essential. Significant challenges related to the indicator's calculation have been noted, which have important implications for the indicator's validity in measuring progress towards meeting the SDG target. Recommendations have been made to revise the scoring of the indicator. This study examines the indicator's validity by proposing a revision to the indicator's calculation that addresses these global concerns and comparing the resulting values.

Methods and findings: This is an observational, validation study which used secondary data from the 2022 United Nations Population Fund's Sexual and Reproductive Health and Rights Country Profiles from 75 countries. To address global recommendations, we proposed making 2 changes to the indicator's calculation. First, we re-expressed all barriers and enablers to take positive values. Second, we used a weighted additive approach to calculate the total score, rather than the mean of the 13 individual component scores, which assigns equal weight to the substantive domains rather than the components. Our main outcome measures are the indicator values obtained from both scoring approaches examined. We assessed the indicator's convergent validity by comparing the value obtained using the indicator's current formula to the proposed formula using the Bland-Altman approach. We examined and interpreted changes in the indicator's overall score that result from comparing the existing indicator with the proposed alternative. Differences in the total value of the indicator comparing the alternative versus the current formulation range from -7.18 percentage points in Mali to 26.21 percentage points in South Sudan. The majority of countries (n = 47) had an increase in total indicator score as a result of the alternative formula, while 27 countries had a decrease in score. Only 1 country, Sweden, saw no change in score, as it scored 100% of the possible indicator value under both rubrics. The mean difference between the scores produced by the 2 measures is 2.28 suggesting that the 2 methods may produce systematically different results. Under the alternative formulation, the most substantial changes were observed in the scores for "Component 3: Abortion." The indicator's current calculation results in 16 countries being assigned a score of zero, for "Component 3: Abortion" which masks important differences in the number of legal barriers present and whether women can be criminally charged for illegal abortion. After re-expressing barriers on a positive scale following the proposed formulation, only 4 countries have a score of zero for Component 3. The main limitation of our methodology is that there is no gold standard for measurement of the phenomenon under study, and thus we are unable to specify with total certainty which indicator performs better.

Conclusions: Our results illustrate underlying challenges with the current indicator formulation that impact its interpretability. The proposed changes could alter the way the current legal landscape governing sexual and reproductive health is understood, thereby pointing to different programmatic and policy priorities that may better support countries in achieving full and equal access to sexual and reproductive health and rights globally.